Effect of Support Tool on Rates of Trial of Labor After Previous Cesarean Delivery Interview with:
Anjali Kaimal, MD, MAS,
Maternal-Fetal Medicine Specialist
Associate Professor in the Departments of Obstetrics
Massachusetts General Hospital
Miriam Kuppermann, PhD, MPH
Professor Vice Chair
Clinical and Translational Research Director
Program for Clinical Perinatal
UCSF What is the background for this study? What are the main findings?

Response: Reducing the rate of cesarean delivery is an important public health goal.  Nearly one third (31.9%) of deliveries in the US are via cesarean, and dramatic increases in the cesarean rate since the 1990s have been associated with substantial increases in maternal morbidity.  One of the reasons for the increased rate of cesarean delivery is the decreasing rate at which women attempt to have a vaginal birth after cesarean (VBAC).  Although having a “trial of labor” (in the hopes of giving birth vaginally) after cesarean is safe, and many women say they would prefer a vaginal delivery, most women who have had a previous cesarean plan a scheduled repeat cesarean delivery.  While some hospitals do not offer trial of labor after cesarean, even at institutions where this is an option. VBAC rates remain low.

We created a patient-facing “decision tool” that provides detailed information on both trial of labor and scheduled repeat cesarean, a personalized risk assessment of the likelihood that the a trial of labor would end in a VBAC, and a series of values clarification exercises, to help women think through their options and engaged in informed, shared decision making with their providers.  We then conducted a randomized study in three geographic areas (San Francisco, Boston, and Chicago) to determine whether use of the decision tool affected rates of trial of labor and vaginal birth after cesarean, as well as several aspects of decision quality (knowledge, shared decision making, decisional conflict, and decision satisfaction). What should readers take away from your report?

Response: In this study of 1485 English-or Spanish-speaking women with one prior cesarean delivery and no prior vaginal birth after cesarean, there were no statistically significant differences in rates of trial of labor and vaginal birth, or in any component of decision quality we measured, when women randomized to use the decision support tool were compared to women randomized to usual care. Overall, study participants experienced relatively high trial of labor and vaginal birth rates and good decision quality regardless of exposure to the decision tool. What recommendations do you have for future research as a result of this study?

Response: The findings from this study suggests that participants made decisions concordant with their preferences and achieved high decision quality regardless of whether they received the decision tool.  Though use of the decision tool did not result in changes in the rate of trial of labor or decision quality in this study, there are reasons to believe that the decision regarding trial of labor versus elective repeat cesarean could benefit from a decision support intervention.  Whether use of this tool would lead to different outcomes in populations with different initial preferences or outcome frequencies is not known. Is there anything else you would like to add? Any disclosures?

Response: Future work is needed to determine whether other populations could benefit from the decision tool.

No disclosures.


Kuppermann M, Kaimal AJ, Blat C, et al. Effect of a Patient-Centered Decision Support Tool on Rates of Trial of Labor After Previous Cesarean DeliveryThe PROCEED Randomized Clinical TrialJAMA. 2020;323(21):2151–2159. doi:10.1001/jama.2020.5952

JAMA. 2020;323(21):2151-2159. doi:10.1001/jama.2020.5952

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